Discrimination Intake Questionnaire

Personal Information

Full name*

All names used in the past

Email*

Phone number*

Address*

Date of Birth*

Married?*
yesno

Race*

Sex*
malefemalenon-binary

Emergency contact (not living with you) name, relationship, and phone*

What is the best way to contact you?*

Name and address of employer at issue*

How many employees of employer at issue?*

Dates of employment with employer at issue
A. Start date B. End date*

Incident Summary

Date of incident*

Type of Discrimination*
—Please choose an option—AgeDisability Medical or Military LeaveNation of OriginReligionRetaliationSexSexual HarassmentWorkers Comp.Other

Date of First/Last Discriminatory Act*
A. First date B. Last date*

Nature of dispute*
Please describe in detail the circumstances leading to and surrounding your dispute*

What was the last Discriminatory Act?

Have you filed an EEOC charge?*

Have you received a right to sue notice from the EEOC?*

Job Title*

Job Duties*

Salary or hourly employee*
salaryhourly

Last salary with employer at issue*

Did you work overtime?*
yesno

Did you work off clock?*
yesno

How many hours worked on a weekly basis*

Fringe benefits: please detail any benefits you received, including but not limited to health, vision, dental, 401k, and/or dependent coverage*

Promotional / disciplinary history

Please describe your promotional history with the employer at issue

Please describe your disciplinary history with the employer at issue

If terminated / disciplined, what was the reason stated for the termination / discipline

Prior or current lawsuits: Have you been involved in any prior lawsuit or are currently involved in any lawsuits (including bankruptcy filings)?

If so, please specify the court, case number, subject matter, and final disposition.

Who will testify for you?
Name, title, number

Who will testify against you?
Name, title, number

Medical/Personal History

Please list all diagnosed medical conditions that relate to your dispute

Please list all medications / prescriptions you currently take that relate to your dispute

Have you been fired from a job?*

Have you been convicted of a crime?*

Criminal: Please detail any arrests, indictments, and / or convictions

Have you ever filed bankruptcy?*

Have you ever filed for SSI?*

Have you ever applied for short term/long term disability through employers benefit?*

Have you applied for unemployment as a result of your termination?*

Did you sign an arbitration agreement with this employer?*

What are your expectations in this lawsuit?*

Any other relevant information

How did you hear about Carter Law Group?